Thursday, September 24, 2020

Obstetrics and Gynecology Needs Palliative Care

by Nathan Riley 

"Can you all, please, just leave us alone?"

One particular experience with the death of a newborn stands out in my mind. Moments after birth the baby was breathless, and the neonatology team could not intubate. All of the kingdom’s pediatric surgeons and other specialists rushed to labor and delivery to no avail. The baby was born with a four centimeter gap in his trachea, an irreparable condition. The mother sat there, holding her dying baby as he took his last breaths while physicians, nurses, and residents were busy as usual. Click-clacking away on computers. Adjusting blankets. Asking questions. Rearranging surgical instruments. This bustle continued until she repeated herself a little more forcefully: “LEAVE US ALONE!”

This experience illustrates how, in a mother’s moment of suffering, a room full of prolific fixers, doers and problem-solvers came up empty-handed. While the loss of a newborn is a relatively rare occurrence, suffering - physical, emotional, psychosocial, or spiritual - is common in the world of women’s health. Likewise, if our only goal on labor and delivery is “healthy baby and healthy mom,” we are without recourse when the normal hazards of being human – many of which are completely out of our control - befall us.

As an obstetrician and palliative medicine specialist, I often wonder how we might approach these challenging scenarios differently. My palliative medicine training taught me that not every problem can - or should - be fixed. My time with patients is often just as well spent sitting in silence as they process the emotions that come with bad news. Even my approach to invasive exams, pregnancy, birth, and pain management is met with an open mind and conversation before putting my steel instruments or medicines to use. After all, a “good outcome” is variable and highly dependent on the patient’s values and goals, and I cannot uphold these values without first building a relationship.

To illustrate how obstetrics and gynecology might be improved through a palliative care touch, let us take a look at one of the most common diagnoses that OBGYNs face in their daily work lives: early pregnancy loss.

Statistically, ten percent of pregnancies end early as a spontaneous abortion or as a “blighted ovum”, in which case the embryo does not develop at all. The diagnosis is thus all too familiar to us providers, but rarely do we consider its gravity on our patients.

The typical clinical routine after a positive over-the-counter pregnancy test is as follows. The patient is greeted on crinkly white paper and positioned in stirrups while the busy clinician offers congratulations. The clinician lubricates and inserts an ultrasound probe into her vagina, swiftly waving the wand around to assess her anatomy. If unable to identify a viable embryo inside the uterus, the clinician resorts to various platitudes to communicate the findings. We are not trained to address anger, sadness, despair, or to consider that this news might even bring relief. In my OBGYN training, my preceptors modeled how to deftly fill any lull in conversation left by the wake of the bad news with generic consolations followed by a list of management options.

Maybe she is facing financial hardship due to the cost of infertility treatments? Maybe this same thing happened in the past and she nearly died from blood loss as a result of a “routine” dilation and curettage? Have you explored whether this is even a desired pregnancy?

A palliative approach to early pregnancy loss would be predominated by conversation, storytelling, and connection, all before a woman is even asked to undress from the waist down. It would include extensive information gathering in order to guide the diagnostic imaging process and align any conversation thereafter with the patient’s expectations and hopes. Early pregnancy failure can be catastrophic to the patient and their partner, and the delivery of this news requires patience and empathy. As with a cancer diagnosis, a patient may not be ready to hear everything that immediately follows the delivery of bad news. With this in mind, it would be better to discuss management options once the patient has had a few moments to process the news, perhaps in an adjacent room away from happily pregnant women or crying newborns. The palliative approach may even include a social worker or chaplain on standby to meet the great psychological, emotional, and spiritual needs for which other clinicians are ill-equipped.

As OBGYNs, we are privileged to play a role in patients’ most intimate experiences, which are often rife with fear, hesitation, and humanity. Our practice ranges from management of suspicious masses to therapeutic abortion, from infertility to debilitating pelvic pain. We are also responsible for guiding conversations around life-limiting or life-threatening prenatal diagnoses.

Challenging experiences – including rare fetal malformations and the all too common early pregnancy loss – abound in women’s healthcare, and many of these experiences lead to varying degrees of worry and suffering on the part of our patients. The adoption of a palliative approach has the potential to transform obstetrics and gynecology to a patient-centered discipline rooted in compassion and informed by our patients’ values.

And yes, when occasional tragedies arise, we must also learn that in birth – as with death – not being able to fix a problem does not imply failure or inadequacy. Sometimes holding space for these tender moments is the only thing to do, and it can be so therapeutic.

Nathan Riley, MD, is an OBGYN and hospice physician with Hosparus Health in Louisville, KY. He also works remotely as a telehealth palliative care physician for Resolution Care.

Thursday, September 24, 2020 by Pallimed Editor ·

Monday, September 21, 2020

Why Writing Down the Good Stuff Can Keep Out the Bad

by Michala Ritz and colleagues

In today’s current world of social isolation and virtual EVERYTHING, it is easy to get sucked down an endless rabbit hole of negativity, sad stories of sickness and death, and scary projections of the future. It is now normal to wake up, wonder about family and friends near and abroad, and monitor the volatile stock market – all while sipping our morning coffee worrying what bad news tomorrow may bring.

Those lingering questions keep us up at night, like monsters under our beds.

“What if I lose my job?”

“What if my parents contract COVID?”

“How will my patients do with all of this?”

“What if I accidentally spread the disease to someone I love?"

“Will life ever be “normal” again?”

Current alterations in daily life due to the coronavirus pandemic have put an enormous mental and emotional strain on countless people throughout the globe.1 Anxiety and depression result from increasing physical and social isolation. There is such a focus on the negative; what activities we cannot do, what events we cannot attend, and what people we cannot see in person. Commonly, the end of the day becomes a time for reflection on the negative, as we replay the conversations, events, and thoughts that did not go well. What’s missing is a healthy dwelling on the good things, the happy moments that brought a quick smile to our faces and joy to our days.

Science and years of research have proven that grateful people are happier and healthier. Gratitude journaling helps people cope with stress and increases the positive emotions that they feel.2 Dr. Martin Seligman has written extensively of the power of positive psychology, and specifically the benefits of gratitude journaling by writing down three positive events or feelings at the end of the day. In doing this, it “changes your focus from the things that go wrong in life, to the things you may take for granted that go well”.3 Gratitude journaling also creates a mentality that is more resilient to adversity and setbacks. Extended research has also shown that promoting resilience training for healthcare workers can lead to lower level of depression, anxiety and an increased overall life satisfaction.4

So, you are telling me, that in order to maintain happiness, healthiness and resiliency, I can reflect on my day and write down three good things that happened? Sounds simple enough. Sign me up! And, guess what, there’s an app for that.

We worked with a software solutions company called CrossComm to build a free, web-based (no download needed) gratitude journaling and sharing app called “The Three Good Things”. We particularly thought about colleagues in palliative care in its design, but also made the app usable for persons outside of healthcare, including our family and friends, patients, and their caregivers. Users of the app can journal privately, or create and invite their own family and friends to join a gratitude sharing network where nightly posts can be seen by those they care about. In doing so, we hope that positivity goes viral, starting from within your own social circles. Further, the app can send you a text or email reminder at the time of your choice to nudge a moment to reflect on the things that are going well.

Here are some examples from the latest rundown of publicly-posted “good things”, known in the app as the “Positivity Feed”.

“Cookie cake and grilled burgers”

“My wife and I are still in love. Like lots.”

“Playing Apples to Apples”

“One week in our new house”

“Cauliflower rice bowls”

“Walked a 5K”

“Thankful for my children”

Just because we have to be a little distant doesn’t mean we need to lose sight of the great lives we all live, the love we experience each day, and the kindness the world still has. We encourage you to take a quiet moment, reflect, and write down your three good things and smile!

The web app can be accessed here: https://the3goodthings.org/

Michala Ritz MPH

Fred Friedman

Jon Nicolla MBA

Don Shin

Arif Kamal MD, MBA, MHS

References

1. Siija, Li et al. The Impact of Covid-19 Epidemic Declaration on Psychological Consequences: A Study on Active Weibo Users. 2020.

2. Allen, S. Is Gratitude Good For Health. 2018.

3. Seligman, M, Steen T, Park N and Peterson, C. Positive psychology progress: empirical validation of interventions. Am Psychol 2005 July – August;60 (5):410 – 421

4. Peccoralo L, Mehta D, Schiller G, et al. The Health Benefits of Resilience. 2020. https://link.springer.com/chapter/10.1007/978-3-030-30892-6_13

Monday, September 21, 2020 by Pallimed Editor ·

Monday, September 14, 2020

Moral Distress and COVID-19: Worlds Collide

by Vickie Leff (@VickieLeff)

As a clinical social worker, I am often approached by my medical colleagues asking for support and a listening ear around difficult cases, understanding their own reactions, team dysfunction, and moral distress. In the middle of this COVID pandemic, Social Workers, Chaplains, Nurses, Physicians, Respiratory Therapists, Child Life Specialists, etc. are all likely experiencing an increase in moral distress. This is due to the necessary change of focus from “patient-centered” to “community -based” approach, and resource allocation issues such as PPE shortage, health inequities, visitation limitations.

A few years ago I wrote another article about Moral Distress. Things have changed since then, compounded by the pandemic. I would like to take a moment to focus on how we can manage these complicated, emotionally charged situations during this incredibly stressful time in which we are challenged about ability, time, strategies to deal with moral distress. Moral Distress challenges clinicians to speak out, work together, and tolerate ambivalence. We must embrace the discomfort in order to legitimize the occurrence and find solutions, especially during this pandemic, when the focus of providers can be easily pulled in many directions. 

“You have to do everything to keep her breathing,” the father of a 15 year old dying of a brain hemorrhage, said to me as the Palliative Care Social Worker. Hearing the panic and desperation in his voice while knowing she would not survive was distressing. Relaying the conversation to the bedside nurse and Resident amplified the distress, as they said what I was thinking: “There is no way she will survive, we have to take her off life support.” Calming myself to be able to have a discussion about the ethics of the situation was challenging, but critical. I worried about whether advocating on behalf of the father would be interpreted as, “the social worker doesn’t get it,” and wondered if they would respect my opinion.

How can we help each other when faced with cases that cause us moral distress? What can our institutions do in response? How can we work as a team to deal with these issues when they arise?

We can remind ourselves that “When addressing moral distress, the aim is not to eradicate the phenomenon but rather to mitigate its negative effects, including preventing caregivers from feeling unable to provide compassionate patient-centered care, feeling withdrawn, unable to return to work or continue in their profession.”

Evidence tells us there are many strategies that can help on the individual, team, and organizational level. It will take deliberate intention, institutional support, and commitment.

Individual Strategies:
Moral distress is not a failing of anyone’s ability to cope with difficult cases, issues, or emotions. By definition, moral distress cannot be “fixed” with an individual effort. Collective action is needed. However, it is important to recognize when we are feeling the personal effects of distress: feelings of anger, frustration, powerlessness, isolation. Those red flags tell us we need to pay attention to what is happening in order to define interventions. Personal strategies raise a paradox. Moral distress is rooted in not being able to effect a change due to organizational barriers and policies that we cannot immediately change. This feeling of powerlessness can be personally immobilizing.

Key suggestions:
- Identify the moral distress issue (i.e. what is it about this situation that is bothering me so much? Is there an ethical question?)

- If you bring the issue to a group/team level, it can mitigate personal frustration and lead to solutions to help the pt/family and individuals. For instance, experiencing a lack of sufficient PPE can clearly create moral distress for individuals. Raising the issue with other colleagues, then bringing it to management collectively, can attend to the individual frustration. The team can begin to have discussions on a level that can affect possible change.

- Often staff will come to the clinical social worker with their case distress, needing support. We can help by differentiating between psychological stress, compassion fatigue, and moral distress – as the interventions vary. [See Sidebar]

- Accept that distress is a normal reaction to something that feels “out of sync,” i.e. out of the ordinary for you. It is critical to not internalize or blame yourself. It isn’t helpful to pathologize your reactions.

- Ask your colleagues to take time and talk about concerns, opinions in order to find avenues for safe, effective solutions. There may be no answer to a morally distressing situation.

- Identify the resources that may be available in/by your workplace, such as your EAP and - those described below.

Institutional/Team Strategies: Moral Distress demands a collective response, between the active team and/or institution. 

- Debriefings. These are scheduled or “on the fly” opportunities for colleagues from all disciplines to discuss a situation. Allowing for differing opinions and possible solutions will help. This process attends to the social isolation that accompanies moral distress.

  - It allows for a safe space for those involved to voice their concerns.
  - It works to create psychological safety
  - It can serve to democratize medical culture.

Ethics Rounds. Many situations evoking moral distress involve ethical issues. Scheduling routine ethics rounds while inviting interprofessional participation can help all of us understand complex issues, voice opinions, and create an atmosphere of safe discussion. If these kind of discussions aren’t happening, and you are not empowered to schedule them yourself, then request them.

Deliberate Interprofessional meetings. There is a lot of information about how to improve team functioning, which would of course add to the capability of teams to support members as they may experience moral distress. While there is evidence that physicians experience moral distress less than nurses and other bedside providers,4 involving all team members works to create a more capable, healthy, team. Moral distress often gets played out between physician and nurses. We must be able to have these difficult conversations in a safe way to ensure all providers have a voice.

And Finally... stop using “Hero” language. If we exalt health care providers (ourselves) to this fantasy status, we deprive them (us) of the normalcy of stress-filled reactions, asking for assistance, de-legitimizing their (our) feelings of powerlessness. As we talk about disenfranchised grief, I believe using this language, during this time, disenfranchises moral distress.

Vickie Leff, LCSW, BCD, APHSW-C is a clinical social worker at Duke Hospice and an Adjunct Instructor for UNC School of Social Work, Chapel Hill. She uses running and humor (not always at the same time!) as her primary coping mechanisms. You can follow her on Twitter

References

1 Morley G, Sese D, Rajendram P, Horsburgh CC. Addressing caregiver moral distress during the COVID 19 pandemic. Cleve Clin J Med. 2020.

2 Dudzinski D. Navigating moral distress using the moral distress map. J Med Ethics. 2016;42:321-324..

3 Dzeng E, Curtis, R. Understanding ethical climate, moral distress, and burnout: a novel tool and a conceptual framework. BMJ Qual Saf. 2018;27:766-770.

4 Fumis R, et.al. Moral Distress and its contribution to the development of burnout syndrome among critical care providers. Annals of Intensive Care. 2017;7(71).

Photocredits: @UnitedNations via Unsplash
Infographic: content by Vickie Leff. Design by Lizzy Miles for Pallimed

Editor's note: The CDC has excellent resources for managing anxiety during COVID-19 here.

Monday, September 14, 2020 by Lizzy Miles ·

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